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ur SAN JOAQUIN COUNTY ULE CO PY ENVIRONMENTAL HEALTH DEPARTMENT LOP Ur I < •' 1 1868 Hazelton Avenue, Stockton, CA 95205-6232 SITE UNIT IVMITIGATION Telephone: (209)468-3147 Fax: (209) 468-3433 Web:www.siaov.oMjtbd WELL & BORING PERMIT APPLICATION FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATION NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San Joaquin County Development Title,Chapter 9-1115.3,and thhet Standards of the /�San wJoaquin County Environmental Health Department. Site Location �►M T�v 7 Cross Street I" CC4{4yal Ass- City/State �ip i 110 APN 2-39502-5 Property n c-� � --/�b' Owner_' ��1 _ Address X D a C54' Sfr I V locity/State�Vl�,ttW,�NtE' ip to ft 9 Phone '104-5 �" �o C-57 Contractor •e! e--(OYe- Address (233 Eke JT 5�� A City/State W0bA0 AjLiC 94(D o l Phone!5 364 -3(,C1C7• Consultant/SubCntr n yr- AddressZkblP(r 17- City/State&A(gcLvt,cLic�aq 4SO _Phones10-& ??q(M Billable Party C, t,'VIrk Address G10( bot1tt, <6441Qd' City/Stated Zip Phone 'v2S-T10-&k3I GIS Coordinates:X Y )&e, CONSTRUCTION WORK TO BE PERFORMED: KPNEW WELLJBORING(CPT.GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) }SOIL BORING IDs ❑WELL IDs ❑OTHER IDs TYPE&#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE -?) ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL ❑PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑PIPE _❑SOIL BORING El PUSH POINT(GP/CPT) GROUT SEAL PUMPED:El Yes Io(MXIMU FR E FALL DEPTH IS 30 FT _❑INJECTION(i.e.AirSoarae.Ozone)KI HAND AUGER GROUT SPECIFICATIONS ��t � tFYIC C(^n.Ny _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 11 5•�] r ❑BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING Ilo El Yes:Casing Dia: Casing Depth: Boring DIa: COMMENTS: `` NOTE: OFFSITE WELLS &BORINGS REQUIRE ACCESS'AGREEMENTS OR ENCROACHMENT PERMITS DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDs: ❑ PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED:❑AUGERS ❑HOSE ❑PIPE ❑MUSHROOM CAP AT L>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS T REQUIRED (AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS I hereby certify th to have r are his a lication and that the work will be done in accordance with San Joaquin County Ordinances, Rules and Regulation , da pp' I i S. /"v` Signed Title/Company er- Print Name Date QQ DEPARTMENT USE ONLY �1 SITE MAP IN UNIT IV FILE-SITE AD RESS l `b �� `�J WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISSUED kZ6 `� AREA I(-i GROUT INSPECTION BY FINAL INSPECTION BY DATE DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE p REQUESpT PR# 2 /O $125x SR# k IfS�Q 3Ca 3�5` G 33S 96 3 C��tn� -Ib-rN Ro# (3500 PR# (2900 C-57WC tl WAIVER ) C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT _ ENCROACHMENT DOCS_ EHD 29-01 5/09/12 WELL PERMIT APP